NUTRITION COUNTRY PROFILE REPUBLIC OF THE SUDAN
FOOD AND AGRICULTURE ORGANIZATION OF THE UNITED NATIONS
Acknowledgments
This profile was prepared by Dr. Osama Awad Salih, Nutrition Centre for Training and Research (NCTR), Sudan, in collaboration with Estelle Bader and Chiara Deligia, Consultants, and Marie Claude Dop, Nutrition Officer, Nutrition Planning, Assessment and Evaluation Service, Food and Nutrition Division, Food and Agriculture Organization of the United Nations.
The assistance of Pr A.H. Khattab and Ms Arwa Ali Mustafa, NCTR, Sudan, and the contribution of volunteers Amélie Solal-Céligny and Fabrizio Mazzarelli are gratefully acknowledged.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 2 Summary
Situated in the north-eastern part of Africa, Sudan has a climate ranging from very arid in the northern parts to equatorial in its most southern parts. The central part is occupied by savannah. The population of the country is approximately 33 million, living in an area of 2.5 million km2. Although urbanization rate is high, the country is still predominantly rural.
More than 90% of the population suffer from poverty and food insecurity. After two decades of civil war, the Comprehensive Peace Agreement signed in early 2005 between the government and the Sudanese Population Liberation Movement, if it is consolidated, could open a new era of stability. Increased revenue from oil exports could boost the economy and have a positive impact on the food security and nutrition situation.
Sudan is both a least developed and low-income food-deficit country. Conflict in the south and western parts of the country compounded by climatic problems such as drought and floods have caused severe food deficits, loss of livelihoods and major population displacements. Moreover, seasonal food shortage often evolves into chronic food insecurity. At the beginning of 2004, WFP and FAO estimated that 3.6 million inhabitants were in need of food assistance, with internally displaced people, refugees and returnees particularly exposed to food insecurity, health problems and insecurity.
Malaria and diarrhea lead the list of endemic diseases along with pneumonia and tuberculosis. Guinea worm infestation is a major health problem across the southern part of the country, where 70% of world cases have been reported. Prevalence of HIV/AIDS is increasing. Populations affected by civil strife are deprived of access to health services and are consequently more vulnerable to diseases and malnutrition.
According to national food balance statistics, the food supply, essentially based on cereals, meets population energy requirements. Vegetable foods are complemented with a substantial supply of milk. Nevertheless, national statistics mask large inequalities in access to food in the country. The prevalence of undernourishment is high. Data on actual food consumption are not available.
Among children under 5 years of age, the prevalence of malnutrition is very high. Based on WHO epidemiologic criteria, the prevalence of stunting and wasting are classified as very high.
Although recent survey data are lacking, there is clear evidence that micronutrient deficiencies are a major public health problem. Prevalence of vitamin A deficiency is high, as observed in 1995 among preschool children. Areas most affected are Southern Darfur and Gezira. Some supplementation campaigns have been conducted but coverage of the population is still low. Prevalence of iodine deficiency is high, as observed among school-age children in 1997. States most at risk were the Upper Nile Zone, Kordofan Zone and Northern Zone. A salt iodization programme has been started but coverage is still very low. Iron deficiency anemia is also highly prevalent among children under 5 years and among women of reproductive age.
Important note: The data presented in this profile pertain to the whole country as regards basic indicators (part I) and food supply data, but most survey data are relevant to northern Sudan only, unless otherwise noted, and sometimes include data from southern cities aggregated as a cluster1.
1 For specific information on southern Sudan, refer to the following document: New Sudan Centre for Statistics and Evaluation in Association with UNICEF. 2004.Towards a baseline: best estimates of social indicators for Southern Sudan. NSCSE Series Paper 1/2004, available on Internet at: http://www.reliefweb.int/rw/RWB.NSF/db900SID/KHII-6365Q7?OpenDocument
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 3 Summary Table Basic Indicators Year Population Total population 32.902 million 2000 Rural population 64 % 2000 Population under 15 years of age 41 % 2000 Population growth rate 1.9 % 2000 Life expectancy at birth 56 years 2000/05 Agriculture Agricultural area 56 % 2002 Arable and permanent cropland per agricultural inhabitant 0.9 Ha 2002 Level of development Human development and poverty Human development index 0.505 [0-1] 2002 Proportion of population living with less than 1$ a day (PPP) MDG1 n.a. Population living below the national poverty line MDG1 n.a. Education Gross primary enrolment ratio MDG2 60 % 2002/03 Youth literacy (15-24 years) MDG2 78 % 2001 Ratio of girls to boys in primary education MDG3 0.85 girl per 1 boy 2001 Health Infant mortality rate MDG4 63 ‰ 2003 Under-five mortality rate MDG4 93 ‰ 2003 Maternal mortality ratio (adjusted) MDG5 590 per 100 000 live births 2000 Malaria-related mortality rate in under-fives MDG6 408 per 100 000 deaths 2000 Environment Sustainable access to an improved water source in rural area MDG7 64 % of population 2002 Nutrition indicators Year Energy requirements Population energy requirements 2 110 kcal per capita/day 2001 Food supply Dietary Energy Supply (DES) 2 270 kcal per capita/day 2001 Prevalence of undernourishment MDG1 27 % 2000/02 Share of protein in DES 13 % 2000/02 Share of lipids in DES 26 % 2000/02 Food diversification index 46 % 2000/02 Food consumption Average energy intake (per capita or per adult) n.a. Percent of energy from protein n.a. Percent of energy from lipids n.a. Infant and young child feeding Age Exclusive breastfeeding rate <6 months 16 % 2000 Timely complementary feeding rate 6-9 months 47 % 2000 Bottle-feeding rate 0-11 months n.a. Continued breastfeeding rate at 2 years of age 40 % 2000 Nutritional anthropometry Stunting in children under 5 years 43 % 2000 Wasting in children under 5 years 16 % 2000 Underweight in children under 5 years MDG1 41 % 2000 Women with BMI<18.5 kg/m² 18 % 1995 Micronutrient deficiencies Prevalence of goitre in school-age children 22 % 1997 Percentage of households consuming adequately iodized salt 0.5 % 2000 Prevalence of clinical vitamin A deficiency in preschool children 3 % 1995 Prevalence of vitamin A supplementation in children 44 % 2000 Prevalence of vitamin A supplementation in mothers 22 % 2000 Prevalence of anemia in women n.a. Prevalence of iron supplementation in mothers n.a. MDG: Millennium Development Goal; n.a.: not available
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 4 TABLE OF CONTENTS
Acknowledgments...... 2 Summary ...... 3 Summary Table...... 4 List of tables and figures ...... 6 Acronyms ...... 7 Part I: Overview and basic indicators ...... 8 I.1 Context...... 8 I.2 Population...... 8 Population indicators ...... 8 Population pyramid for 2001...... 9 I.3 Agriculture ...... 9 Land use and irrigation statistics ...... 10 Main food crops, agricultural calendar, seasonal food shortage ...... 10 Livestock production and fishery ...... 11 I.4 Economy ...... 11 I.5 Social indicators ...... 12 Health indicators ...... 12 Water and sanitation...... 13 Access to health services ...... 14 Education ...... 14 Level of development, poverty...... 15 Other social indicators ...... 15 Part II: Food and nutrition situation ...... 16 II.1 Qualitative aspects of the diet and food security...... 16 Food consumption patterns ...... 16 Food security situation...... 16 II.2 National food supply data ...... 17 Supply of major food groups...... 17 Dietary energy supply, distribution by macronutrient and diversity of the food supply...... 18 Vegetable/animal origin of macronutrients ...... 19 Dietary energy supply by food group...... 19 Food imports and exports ...... 20 Food aid ...... 22 II.3 Food consumption...... 22 National level surveys...... 22 II.4 Infant and young child feeding practices ...... 22 II.5 Nutritional anthropometry...... 23 Low birth weight...... 23 Anthropometry of preschool children...... 23 Anthropometry of school-age children and adolescents ...... 27 Anthropometry of adult women...... 27 Anthropometry of adult men ...... 27 II.6 Micronutrient deficiencies...... 27 Iodine deficiency disorders (IDD)...... 27 Prevalence of goitre and urinary iodine level ...... 27 Iodization of salt at household level ...... 28 Vitamin A deficiency (VAD)...... 29 Prevalence of sub-clinical and clinical vitamin A deficiency...... 29 Vitamin A supplementation...... 30 Iron deficiency anemia (IDA) ...... 31 Prevalence of IDA...... 31 Interventions to combat IDA ...... 32 II.7 Policies and programmes aiming to improve nutrition and food security ...... 33 Reference list ...... 34
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 5 List of tables and figures
List of tables Table 1: Population indicators ...... 9 Table 2: land use and irrigation ...... 10 Table 3: Livestock and fishery statistics ...... 11 Table 4: Basic economic indicators...... 12 Table 5: Health indicators...... 13 Table 6: Access to safe water and sanitation...... 14 Table 7: Access to Health Services...... 14 Table 8: Education...... 15 Table 9: Human development and poverty ...... 15 Table 10: Other social indicators...... 15 Table 11: Trends in per capita supply of major food groups (in g/day)...... 17 Table 12: Share of the main food groups in the Dietary Energy Supply (DES), trends ...... 20 Table 13: Type of infant and young child feeding ...... 23 Table 14: Anthropometry of preschool children ...... 25 Table 15: Prevalence of goitre and level of urinary iodine in school-age children...... 28 Table 16: Iodization of salt at household level ...... 29 Table 17: Prevalence of clinical vitamin A deficiency in children under 5 years...... 30 Table 18: Vitamin A supplementation of children and mothers...... 31 Table 19: Prevalence of anemia in preschool children ...... 32 Table 20: Prevalence of anemia in women of childbearing age...... 32
List of figures Figure 1: Dietary energy supply (DES), trends and distribution by macronutrient ...... 18 Figure 2: Vegetable/animal origin of energy, protein and lipid supplies...... 19 Figure 3: Dietary energy supply by food group...... 19 Figure 4: Major food exports as percentage of Dietary Energy Supply (DES), trends...... 21 Figure 5: Major food imports as percentage of Dietary Energy Supply (DES), trends...... 21
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 6 Acronyms BMI Body mass index CBS Central Bureau of Statistics CDC Center for Disease Control and prevention CED Chronic energy deficiency DES Dietary energy supply DPT3 Diphtheria, pertussis (whooping cough) and tetanus vaccine – three doses ECOSOC Economic and Social Council of the United Nations ENN Emergency Nutrition Network FAO Food and Agriculture Organization of the United Nations FAOSTAT FAO Statistical Databases FIVIMS Food Insecurity and Vulnerability Information and Mapping Systems FMH Federal Ministry of Health GDP Gross domestic product GIFA Geneva Infant Feeding Association GNP Gross national product GOS Government of Sudan HIV/AIDS Human immunodeficiency virus/ acquired immuno deficiency ICCIDD International Council for the Control of iodine Deficiency Disorder IDA Iron deficiency anemia IDD Iodine deficiency disorders IDP Internally displaced person ILO International Labour Organization IRIN United Nations’ Integrated Regional Information Network ITU International Telecommunication Union MAF Ministry of Agriculture and Forestry MICS Multiple Indicator Cluster Survey MOH Ministry of Health NSCSE New Sudan Centre for Statistics and Evaluation PPP Purchase power parity SSC Southern Sector Counterparts SPDF Sudan People's Democratic Front SPLM/A Sudanese Population Liberation Movement / Army SuRF Surveillance of chronic disease Risk Factors UNAIDS Joint United Nations Programme on HIV/AIDS UN United Nations UNDP United Nations Development Nations UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Population Fund UNHCR United Nations High Commissariat for Refugees UNICEF United Nations Children’s Fund UNPD United Nations Population Division UNSTAT United Nations Statistics Division VAD Vitamin A deficiency WB World Bank WFP World Food Programme WHO World Health Organization
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 7 Part I: Overview and basic indicators
I.1 Context
Located in north-eastern Africa, the Republic of the Sudan is the largest country in Africa 2 (2 505 000 km ). The landscape is a basin-like plain with an elevation between 300 to 900 meters, crossed by the Nile River and its tributaries. There are a few groups of hills and a mountain range in the south, the Imatong Mountains, rising to over 1 500 m, the Djebel Mara mountain (3 090 m) in Darfur province in the west and the Red Sea Hills (over 2 000 m) in the north-east near the coast. The highest point in Sudan, Kinyeti (3 187 m), is in the southeast. Generally speaking the country can be divided into three natural regions. The north of Khartoum is primarily desert. The central part of the country is mostly a grass-covered plain. The south contains a vast swamp, the Sudd, and rain forest.
The country has a range of tropical and continental climates with large daily and seasonal fluctuations in temperature. In the desert, winter minimum temperatures as low as 5°C are common at night, while summer maximum temperatures often exceed 44°C. Dust storms occur frequently. In the vicinity of Khartoum the average annual temperature is about 27°C. Temperatures, humidity and rainfall are all higher in the south. There is a large variation in annual rainfall, from less than 75 mm in the desert, 75 mm to 300 mm in the semi-desert, 300 mm to 1 500 mm in the forests and savannas and to over 1 500 mm in the mountains (FAO, Forestry Division). Sudan is both a least developed and low-income food-deficit country, which has been ravaged by civil strife across the south for two decades. A very long civil war between government forces and the Sudanese People's Liberation Movement/Army (SPLM/A) has killed an estimated two million people, mostly from hunger and disease, and displaced an estimated of four million. In 2003, a new conflict emerged in West Darfur (WFP, 2005a). Although a Comprehensive Peace Agreement was signed between the Government and the SPLM/A in January 2005, the situation in the South and in Western Darfur remains unsettled (UN, 2005). The death, on July 31, 2005, of the Sudanese vice president and key actor of the peace process John Garang has brought back unrest and violence throughout the country.
I.2 Population
Population indicators The Sudanese population is very young: 40% is less than 15 years of age. Although the country is still predominantly rural, urbanization is progressing rapidly and is a major concern for policy makers and planners. The civil war, drought, and poverty have further reinforced the population concentration in towns. Moreover, Sudan hosts a considerable number of internally displaced people (IDP) (about 700 000 as per end of 2004) and refugees from neighbouring countries (about 200 000 as per end of 2004) (UNHCR, 2004 & 2005).
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 8 Table 1: Population indicators Indicator Estimate Unit Reference Period Source Total Population 32 902 thousands 2000 UNPD Annual population growth rate 1.9 % 2000 UNPD Crude birth rate 33.5 ‰ 2000 UNPD Population distribution by 2000 UNPD age: 0-4 years 15.2 % 5-14 years 25.3 % 15-24 years 20.4 % 60 and over 5.3 % Rural population 64 % 2000 UNPD Agricultural population 61 % FAOSTAT Population density 13 inhabitants per km2 2000 UNPD Median age 19 years 2000 UNPD Life expectancy at birth 56 years 2000-2005 UNPD males per 100 Population sex ratio 101.2 2000 UNDP female Net migration rate -3 ‰ 2000-2005 UNPD Total dependency rate 78 % 2000 UNPD
Population pyramid for 2001
Source : UNAIDS, 2002
I.3 Agriculture The agricultural sector plays a pivotal role in the economy of the country. It consists of five interdependent sub-sectors, namely irrigated, traditional rain-fed, mechanized rain-fed, livestock, and forestry (Kambal, 1997; Abdel Ati, 2001a). The irrigated farming system covers 1.9 million ha, irrigated mainly by the Nile and its tributaries. Public corporations (Gezira, Rahad and New Halfa) dominate the sector (about 68% of the total irrigated area). The main crops grown under irrigation are cotton, wheat, sorghum, groundnuts, pulses, green fodder, fruits and vegetables, and sugar cane (Kambal, 1997; Abdel Ati, 2001a). The mechanized farming system is practiced in the central clay plains. Mechanization is still only partial, covering land preparation, seeding, harvesting, and threshing of sorghum. Sorghum and sesame are the main crops grown in this sector, while sunflower and guar have recently been introduced (Kambal, 1997; Abdel Ati, 2001a).
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 9 The traditional rain-fed farming system is practiced on about 3.75 million ha located mainly in western Sudan (Kordofan and Darfur), the southern region, and some parts of the central region (Kambal, 1997; Abdel Ati, 2001a). As farming in this sector depends mainly on family labour using hand tools, the area farmed by each family is usually small. Some crops are cultivated every year without rotation or addition of fertilizers. Consequently, soils are poor and yields are low. It is estimated that 75% of the agricultural population in Sudan live in the traditional sub-sector.
About 47% of the land resources are under arid and semi-arid conditions with serious drought risks (FAO, FAOSTAT Database). Of the total agricultural area of the country, 64% is degraded. The principal causes of degradation are soil erosion, siltation and flooding, deterioration of soil fertility, exhaustion of water supplies and deforestation. About 80% of agricultural land is deficient in nitrogen, phosphorus, and organic matter, the main limiting factors in agricultural production. About 200 000 ha of natural woodlands and forests are annually replaced by dry land mechanized agriculture (FNC, 2000). Apart from the visible signs (erosion, siltation and flooding), common indicators of degraded land are declining yields, increased weeds, declining recharge to wells and boreholes, and poor ground water quality (Abdel Ati, 2001a; FAO/WFP, 2002).
Land use and irrigation statistics Table 2: land use and irrigation Type of area Estimate Unit Reference period Source Total Land Area 237 600 1000 Ha 2002 FAO Agricultural Area 56 % 2002 FAO Arable lands & Permanent Crops 7 % 2002 FAO Permanent Crops <1 % 2002 FAO Permanent Pasture 49 % 2002 FAO Forested land areas 26 % 2000 FAO Irrigated agricultural land <1 % 2002 FAO Arable & Permanent cropland in 0.9 Ha 2002 FAO Ha per agricultural inhabitant N.B. Percentages are calculated on total land area.
Main food crops, agricultural calendar, seasonal food shortage The major food and agricultural commodities produced in Sudan in 2002 were sugar cane, sorghum, cow and goat milk, groundnuts, millet and tomatoes (FAO, Statistics Division). All these commodities are mainly destined to local human consumption (FAO, FAOSTAT Database).
Source : GIEWS
The food shortage season in Sudan corresponds to the rainy season, which ranges from August to October in the north and June to August in the south.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 10 Livestock production and fishery Livestock production contributes significantly to the Gross Domestic Product (GDP) and to the food security of the country. It is mainly nomadic, based on free utilization of rangelands through seasonal movements. Due to the long distances covered, the productivity is rather low. The semi-nomadic pastoral system is based on the utilization of crop residues remaining from rain fed agriculture in the Savannah region, as well as on natural grazing in the area, and the sedentary one is based on sheep and goats raised in small villages in western Sudan. The major constraints facing livestock rearing in Sudan include feed shortage, overgrazing, desertification, lack of breed resources and lack of adequate veterinary services (FAO, 2000; Abdel Ati, 2001a).
Table 3: Livestock and fishery statistics Livestock production and Estimate Unit Reference period Source fishery Cattle 38 183 000 number of heads 2002 FAO Sheep and Goats 89 621 000 number of heads 2002 FAO Poultry Birds 37 000 thousands 2002 FAO Fish catch and aquaculture 59 600 tons 2002 FAO
The contribution of fisheries to the Sudan GDP is presently marginal (0.4%). The per caput supply was only 1.6 kg /year in 2000, mostly obtained by capture fish. The inland fisheries are based on the Nile River and its tributaries, contributing over 90% of the estimated production potential of the country. Marine fisheries consist mainly in harvesting of wild molluscs and finfish, activities of a traditional and subsistence nature (FAO, 2002).
I.4 Economy
The economy of Sudan is based on agricultural production, which represents a major share of the GDP. Oil production is becoming an important sector of the economy. Lack of transport infrastructure is a serious constraint to economic development. The country’s vast area and the availability of only one major outlet to the sea, Port Sudan, place a heavy burden on limited facilities, especially on the government-owned Sudan Railways and on the road network. The government-owned Sudan Airways airline operates domestic and international services from Sudan’s main airport in Khartoum. There are several smaller airports (mainly Al-Ubayyid and Port Sudan). An oil pipeline goes from the oil fields in the South via the Nuba Mountains and Khartoum to the export terminal in Port Sudan on the Red Sea (UNDP, 2003). The main non-agricultural commodities exported in 2001 were oil and petroleum products. The main non-agricultural products imported were manufactured goods, refinery and transport equipment, medicines, chemicals and textiles (WB, 2003). The infusion of foreign investment as well as increased revenue from oil production (in 1999-2000 Sudan recorded its first trade surplus) injected new capital into some sectors of the economy. The country has taken some steps to move from a socialist to a market-based economy and has started to reform its finance and foreign exchange systems. The public sector remains however dominant in the economy (Abdel Ati, 2001a).
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 11 Table 4: Basic economic indicators Indicator Estimate Unit Reference Period Source Gross Domestic Product per capita 1 970 PPP US $ 2001 UNDP GDP annual growth 6 % 2002 WB Gross National Income per capita 400 $ 2002 WB Industry as % of GDP 18 % 2002 WB Agriculture as % of GDP 39 % 2002 WB Services as % of GDP 43 % 2002 WB Paved roads as % of total roads 36 % 1999 WB Internet users 0.3 per 10 000 people 2002 ITU Total debt service as % of GDP 1 % 2002 WB Military Public expenditure 2.8 % of GDP 2002 UNDP
I.5 Social indicators
Health indicators Health problems in Sudan are acute and complex. Large-scale population displacements due to the long-lasting conflict, natural disasters such as drought and floods, the cycle of poverty, malnutrition and loss of productivity expose populations to serious diseases such as malaria, tuberculosis and meningitis. After floods and other natural disasters, diarrhea is a common occurrence. Guinea worm infestation is a major health problem across the southern part of the country, where 70% of world cases have been reported. The disease is highly debilitating (UNICEF, 1999; UN, 2000). HIV/AIDS prevalence is growing rapidly. Most of the cases reported were from the south, east, and Khartoum State regions (UN, 2000). In late 2004, UNICEF and UNFPA expressed concern that increased mobility of the population, as stability returned to the southern region, could accelerate the spread of HIV infection to rural communities, which had remained isolated during the war and retained low infection rates. The phenomenon could be exacerbated by the lack of HIV/AIDS awareness among this population, coupled with the already high HIV prevalence in some garrison towns (IRIN, 2004). Immunization rates are low, especially among pregnant women, as well as use of Oral Rehydration Therapy, reflecting the lack of access to health care services. The level of infant and underfive mortality is probably underestimated. In the north, the infrastructure network and the workforce are quite developed in absolute numbers. However, up to a third of health facilities are reported not to be fully functional. In the south, overall coverage is estimated at only 25% of the population. Infrastructure is inadequate, geographically concentrated and in poor condition. Most health services are supported by international Non- Governmental Organizations (NGOs) under humanitarian programmes (IRIN, 2004).
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 12 Table 5: Health indicators Indicator Estimate Unit Reference Period Source Mortality Infant mortality 63 ‰ 2003 UNICEF Under-five mortality 93 ‰ 2003 UNICEF Maternal mortality ratio : UNICEF per 100 000 reported 550 1985-2003 UNICEF live births per 100 000 adjusted 590 2000 UNICEF live births Morbidity per 100 000 Malaria-related mortality rate in 408 deaths in 2000 UNSTAT under-fives under-fives Percent of under-fives sleeping 0.4 % 2000 UNSTAT under a treated bed net Prevalence of diarrhea in the last 2 30 % 1990 UNICEF/MICS weeks in under-fives Oral Rehydration rate among 38 % 2000 UNICEF/MICS under-fives Percentage of under-fives with acute respiratory infections in the 5 % 2000 UNICEF/MICS last 2 weeks per 100 000 Tuberculosis prevalence 372 2000 UNSTAT people AIDS/HIV Prevalence in adults 2.3 % 2003 UNSTAT Percent of women (15-24) who know that a person can protect herself 12 % 2000 UNSTAT from HIV infection by consistent condom use Immunization Percent of infants with immunization 53 % 2003 UNICEF/WHO against tuberculosis at 1 year of age Percent of infants with DTP3 50 % 2003 UNICEF/WHO immunization at 1 year of age Percent of infants with immunization 57 % 2003 UNICEF/WHO against measles at 1 year of age Percent of pregnant women 35 % 2003 UNICEF/MICS immunized against tetanus
Water and sanitation The situation regarding access to an improved water source and sanitation facilities varies strongly from one region to another. The situation in Darfur for example is considerably worse than in other states: only 26 % of the population have access to an improved water source compared to an average of 64% in rural areas of the country taken together (Table 6) (FMH, CBS & UNICEF, 2001). In 2002, 24% of the population of rural areas had access to adequate sanitation facilities, while the proportion was 50% in urban areas (UNICEF, information by country).
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 13 Table 6: Access to safe water and sanitation Indicator Estimate Unit Reference period Source Sustainable access to an improved water source: Urban 78 % of population 2002 WHO Rural 64 % of population 2002 WHO Access to improved sanitation: Combined urban/rural 34 % of population 2002 UNICEF
Access to health services Health services are concentrated in urban areas while, in terms of health personnel and facilities, rural areas still suffer from inadequate preventive and curative services (UNICEF, 2004).The expansion of health facilities has not matched population growth, and civil strife has destroyed many previously operating health facilities. Ineffective coverage is manifested in lack of infrastructure, insufficient stocks of drugs and medical equipment, and lack of skilled health personnel (UN, 2003). About 60% of women receive some sort of antenatal care (UNICEF, 2004). Nevertheless, the limited and inequitable access to essential child and mother health care services accounts for the high maternal mortality rates. Table 7: Access to Health Services Reference Indicator Estimate Unit Source Period per 100 000 Health personnel: number of physicians 16 1990-2003 WHO people Population with sustainable access to very low 1999 UNDP affordable essential drugs access* Percent of births attended by skilled 86 % 1993 UNICEF health personnel Public expenditure on Health 0.6 % of GDP 2001 UNESCO * estimated at 0-49%
Education The Government provides free primary education from the ages of 7 to 12 years and aims at expanding it to all school age children by the year 2010. However, many obstacles remain, such as economic circumstances leading to high drop-out rates (24% in 1999) in primary schools and low enrolment in secondary schools. School structures are inadequate and deficient in terms of classroom furniture, water supply and sanitation (UN, 2003). Around 45% of schools in southern Sudan function in the open, under trees and in this region the percentage of permanent classroom structure is just 11%. Of these, more than half do not have a source of safe drinking water and almost three quarters are without latrines (UN, 2003). The south remains the most educationally deprived region of the country, with less than one-seventh of the total number of primary schools of the country, despite a population representing more than one-quarter of the total population of the country (ECOIN, 2003). According to the Ministry of Education, overall enrolment was 40% at national level, while in the southern states it was only 11% (UN, 2002a; UNICEF, 1999). The disparity in literacy rates between boys and girls has narrowed in recent years, presently the adult literacy ratio is 69% for males and 46% for females (UNICEF, 2004).
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 14 Table 8: Education Indicator Estimate Unit Reference Period Source Adult literacy 59 % 2001 UNESCO Adult literacy rate : females as % of males 68 % 2001 UNESCO Youth literacy (15-24 years) 78 % 2001 UNESCO Gross primary enrolment ratio 60 % 2002-2003 UNESCO Grade 5 completion rate 84 % 2002 UNESCO number of Ratio of girls to boys in primary education 0.85 2001 UNESCO girls per 1 boy Public expenditure on education 1.4 % of GNP 1995-97 UNESCO
Level of development, poverty Poverty is widespread in Sudan, and the poorest regions are those of Darfur, Kordofan as well as Blue Nile and rural Red Sea (Abdel Ati, 2001b). The situation was furthermore aggravated in the past two decades by government military spending pre-empting other social and economic investment (UNDP, 2003), and civil strife causing the progressive dismantling of traditional coping strategies. Progress to reduce poverty is typically measured through the percentage of the population living on less than $1 a day and under the national poverty line. In Sudan, reliable data on both variables are not available, however, based on proxy measures, there is consensus amongst all observers that income poverty has increased in the 1990’s (UN, 2002a). Table 9: Human development and poverty Indicator Estimate Unit Reference period Source value Human development index (HDI) 0.505 2002 UNDP between 0-1 Proportion of population living with n.a. less than 1$ a day (PPP) Population living below the national n.a. poverty line Human poverty index (HPI-1) 31.6 % 2002 UNDP n.a. : not available
Other social indicators Because of male military enrolment and disappearances during the conflict, women have been left with a greater burden than traditionally, which includes child care, working in the fields, and any activity bringing a minimal financial income. Most IDPs are women, children and elderly. Women have been the preferential victims of sexual abuse and violence (ECOSOC, 2004). Incidents of forced military recruitment of children of both sexes occurred during the conflict, combined with voluntary enrolment of children trying to escape conditions of extreme poverty (UNICEF, 2002a). Between 2001 and 2003, 20 000 child soldiers both in northern and southern Sudan were demobilized from the SPLM/A and the SPDF with the support of a special UNICEF/WFP task force. The demobilization of children from government forces and allied militia is also needed (Robertson & McCauley, 2004). Table 10: Other social indicators Reference Indicator Estimate Unit Source period Value Gender related development index (GDI) 0.485 2002 UNDP between 0-1 Women’s wage employment in non- agricultural sector as % of total non 19 (estimate) % 2003 UNSTAT agricultural employees Ratification of ILO Convention 182 on The ratified 2003 ILO Worst Forms of Child Labour
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 15 Part II: Food and nutrition situation
II.1 Qualitative aspects of the diet and food security
Food consumption patterns Differences in food availability, climate, as well as regional food habits and traditions result in considerable regional variation in food consumption patterns in Sudan. Sorghum is the main staple of a major part of the rural population. Millet, along with sorghum, is especially important in western Sudan, while wheat, mainly consumed as bread, is of increasing importance to the diet in urban areas and in the north. Cassava, yams and sweet potatoes are the main staples in the southern region. In many areas of the south, maize and milk contribute substantially to the diet, and in some tribal areas, as much as 40% of all food consumed is milk and dairy products. For the nomadic population, milk (from cows, sheep, goats and camels) is sometimes the main source of energy, protein and other nutrients (Dirar, 1993). Legumes, grown and consumed mainly in the northern part of Sudan, include beans, peas and cow- peas. In urban areas, broad beans are generally eaten as a main dish for both breakfast and dinner. The consumption of fresh vegetables, especially green leafy varieties, and of fruit, with the exception of dates, is limited. Okra is eaten in dried form and tomatoes and onions are eaten in urban areas. Mutton and beef are favoured over other types of meat. Consumption of fish is low. Most of the fish eaten is inland freshwater fish, while sea fish is consumed only along the Red Sea coast. Groundnuts and sesame are the main sources of local vegetable oils (MAF, 2001).
Food security situation As defined by FIVIMS, food security is defined as “A situation that exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life”. Food insecurity may be caused by the unavailability of food, insufficient purchasing power, inappropriate distribution, or inadequate use of food at the household level. Food insecurity may be chronic, seasonal or transitory. Many areas in Sudan have suffered from recurrent periods of acute food insecurity for at least a generation. Drought and other climatic variations are only one factor among many that have contributed to food insecurity. War and underdevelopment have resulted in high underlying vulnerability and a reduced ability to fall back on alternative sources of food or income when times are hard (UNICEF, 2003). In 2004/05, the overall food security situation throughout the country deteriorated, mainly because of erratic and unevenly distributed rainfall experienced during 2004. In general, the most vulnerable are people recently displaced who have extremely limited access to land and other income generating opportunities (WFP, FAO, NGOs, GOS & SSC, 2005). Poverty is also a major factor of food insecurity in Sudan. Most of the poor are rural residents but urban poverty is also increasing because of population displacement. In the agricultural sector, food security is based on consumption of own production, with farmers selling their surplus for cash in good years and using a variety of other livelihood strategies to reduce vulnerability to recurrent drought and food deficit. The livelihood systems, which vary greatly according to specific locations, encompass livestock, agriculture, fishing, gathering of wild foods and trade. However, due to civil strife, these livelihood systems have experienced frequent stress. Insufficient availability of food is a major cause of food insecurity. In 1983/84 drought caused a decline in cereal supply (particularly for sorghum and millet). After this period, there have been fluctuations in cereal supply (Guvele et al, 2004). Recent food security assessments have highlighted the reduced cereal food production throughout Sudan. For 2004/05, the level of cereal production is estimated about half of the bumper cereal crop harvested in 2003/04 and 28% below the average of the last five years.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 16 Another major cause of food insecurity in certain regions of Sudan is the absence of physical access to food due to civil insecurity. Conflicts, violence and internal displacement limit access to food (WFP, 2004b). In many areas, harvests have been destroyed, livestock has been looted and food stocks have reduced rapidly since residents often share their resources with IDPs. In conflict affected areas, cereal stocks in markets are low and prices increase sharply in times of strife. Moreover insecurity drastically reduces food commodity flows from surplus to deficit areas (WFP, 2005b). In addition, diseases such as Guinea worm infestation and malnutrition debilitate populations, affecting their physical capacity to produce food and causing improper utilization of nutrients (Guvele et al, 2004).
II.2 National food supply data
Supply of major food groups Table 11: Trends in per capita supply of major food groups (in g/day) Supply for human consumption in g/day Major food groups 1965-67 1972-74 1979-81 1986-88 1993-95 2000-2002 Cereals (excl. beer) 286 359 337 380 426 380 Starchy roots 70 45 38 23 14 13 Sweeteners 38 51 55 58 42 51 Pulses, nuts, oilcrops 33 25 25 23 27 34 Fruit and vegetables 205 207 187 174 160 165 Vegetable oils 16 29 29 21 19 19 Animal fats 3 3 4 4 3 4 Meat and offals 63 63 71 52 60 67 Fish, seafood 4 4 4 3 4 5 Milk and eggs 239 217 325 338 394 417 Other 58 72 65 4 4 5 Source: FAOSTAT
Cereals, and milk and eggs constitute the main food groups in terms of supply for human consumption. Milks and eggs are the major group, which increased from 239g/per capita/day in 1965/67 to 417g/per capita/day in 2000/02. This increase is probably due to the growing number of dairy farms, particularly around Khartoum. Overall, the per capita supply of cereals (mainly wheat, sorghum and millet) has increased over the same period, from 286g/day to 380g/day respectively. However, the supply has decreased in 2000/02 compared to the level of 1993/95. Starchy roots, such as cassava, yams and sweet potatoes, are the main staples in the southern region. Their supply declined drastically from 70g/per capita/day in 1965/67 to 13g/per capita/day in 2000/02. Pulses and oilcrops are grown and consumed mainly in the northern part of the country. Their per capita supply was about 34g/day in 2000/02. Fruit and vegetables supply has been decreasing moderately since 1979/81. The meat supply, principally bovine, mutton and goat meat, has been fairly stable from 1965 to 2002. The Sudanese diet is essentially composed of cereals, milk, eggs, fruit and vegetables. Fruit and vegetables provide good sources of micronutrients, but the supply of meat and fish, which are other good sources of micronutrients, is limited.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 17 Dietary energy supply, distribution by macronutrient and diversity of the food supply • Figure 1: Dietary energy supply (DES), trends and distribution by macronutrient Figure 1: Trends in DES per capita and percentages from protein, lipids & carbohydrates
2500
2000
y 1500 58 62 61 a 61 62 d / l 61 a c
k 1000
30 25 26 500 26 28 26
12 11 12 12 13 13 0 1965-67 1972-74 1979-81 1986-88 1993-95 2000-2002
Sudan protein lipids carbohydrates Source: FAOSTAT
In 2001, the dietary energy supply (DES) was 2 270 kcal/per capita/day, a level barely meeting population energy requirements of 2 110 kcal per capita/day2. According to “The State of Food Insecurity in the World” (SOFI) the prevalence of undernourishment was 27% in 2000/02 (FAO, 2004b). The share of protein, lipids and carbohydrates in the dietary supply has remained stable from 1965/67 to 2000/02. Currently, the share of lipids is adequate in comparison to recommendations (energy from lipids not exceeding 30%) (WHO, 2003).
2 Energy requirements are for a healthy and active lifestyle calculated using the FAO software (FAO, 2004a). Software default values attribute to 90 % of the urban adult population a light physical activity level (PAL=1.55) and greater than light activity to the remaining 10% (PAL=1.85), and to 50% of the rural adult population a light activity (PAL=1.65) and greater than light physical activity (PAL=1.95) to the other 50%.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 18 Vegetable/animal origin of macronutrients • Figure 2: Vegetable/animal origin of energy, protein and lipid supplies Figure 2: Origin of energy, protein and lipid supplies, 2000-2002 Vegetable/animal origin (in % ) 100 Percentage of animal origin 90 20 Percentage of vegetable origin 80 37 46 70
60
50
40 80
30 63 54 20
10
0 Energy Protein Lipid Sudan, 2000-2002 Source: FAOSTAT
Macronutrients are essentially of vegetable origin, ranging from 80% for energy to 54% for lipid. This is due to the importance of vegetable food groups (cereals, sweeteners, oil, pulses, fruit and vegetables) in the DES.
Dietary energy supply by food group • Figure 3: Dietary energy supply by food group Figure 3: Percentage of energy provided by major food group in 2000-2002
Starchy roots 1% Animal fats 1% Fruit & vegetables 4%
Meat and offals 6%
Pulses, nuts, oilcrops 6%
Vegetable oils 7%
Cereals (ecxl. beer) 53% Sw eeteners 8%
Milk and eggs 13% Sudan Source: FAOSTAT N.B. Values under 1% are not presented.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 19 Cereals provide more than half of the DES in Sudan (53%). Milk and eggs rank second (13%) and sweeteners provide 8% of the DES. Thus, almost ¾ of the energy supply comes from 3 foods groups, cereals, milk and sweeteners. Table 12: Share of the main food groups in the Dietary Energy Supply (DES), trends % of DES Food groups 1965-67 1972-74 1979-81 1986-88 1993-95 2000-2002 Cereals (excl. beer) 50 53 49 55 58 53 Starchy roots 4 2 2 1 1 1 Sweeteners 7 8 9 10 7 8 Pulses, nuts, oilcrops 8 5 5 5 5 6 Fruit and vegetables 5 4 4 3 3 4 Vegetable oils 8 12 12 9 7 7 Animal fats 1 1 1 1 1 1 Meat and offals 7 6 6 5 5 6 Fish, seafood <1 <1 <1 <1 <1 <1 Milk and eggs 9 7 11 11 13 13 Others 1 1 1 <1 <1 <1
The share of cereals in the DES has globally increased from 1965/67 to 2000/02, with a slight decrease during the last period (2000/02). There was a drop in the DES provided by starchy roots from 4% to 1% during the period from 1965/67 to 2000/02. The part of non staple food groups in the DES has decreased during the same period. This decrease concerned pulses, fruit and vegetables, vegetable oils and meat. Only the DES provided by milk and eggs and by sweeteners has increased. The food diversification index remained stable between 1965/67 and 2000/02 (46% for both periods). Lack of progress in the level of the diversification index can be attributed to the many problems the country faces periodically, namely drought, conflict and food insecurity.
Food imports and exports Overall, exports have declined during the period from 1965/67 to 2000/02. Oilcrops represented a major share in 1965/67, but have since declined significantly. Exports of cereals have slightly increased from 1965/67 to 1993/95 but fell considerably in 2000/02.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 20
• Figure 4: Major food exports as percentage of Dietary Energy Supply (DES), trends Figure 4: Food exports expressed as percentage of DES. Trends from 1965-67 to 2000-2002.
20 18 16 14
S 12 E D
f 10 o
% 8
6 Oilcrops 4 2
0 Cereals (excl. beer) 1965-67 1972-74 1979-81 Vegetable oils 1986-88 Sudan 1993-95 Source: FAOSTAT 2000-2002
Note that only the 3 most important food groups are shown
There were major shifts in imports over the period 1965/67 to 2000/02. Imports of cereals have increased considerably and represented about 14% of DES in 2000/02. Imports of sweeteners were reduced because of the increasing production capacity of the local sugar cane industry. Imports of vegetable oils have increased since the mid-1980s.
• Figure 5: Major food imports as percentage of Dietary Energy Supply (DES), trends Figure 5: Food imports expressed as percentage of DES. Trends from 1965-67 to 2000-2002.
20 18 16 14 Cereals (excl. beer) S 12 E D
f 10 o
% 8 6 4 2 0 Sw eeteners 1965-67 1972-74 1979-81 Vegetable oils Sudan 1986-88 1993-95 Source: FAOSTAT 2000-2002
Note that only the 3 most important food groups are shown.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 21 Food aid In 2003, Sudan received a total food aid of 252 311 t. Eighty-six percent were cereals (distributed as 61% of coarse grains, 33% of wheat flour and 6% of blended/fortified commodities) and 14% were other foods (distributed as 57% of pulses, 38% of oils and fats, and 5% of various other commodities). This food aid was mainly delivered as emergency food aid (91%), with a small part delivered as project food aid (9%). No programme food aid was delivered3 (WFP, 2004). The Sudan emergency operations posed a major challenge in ensuring timely and cost-effective deliveries. Lack of basic infrastructure, seasonal lack of access to roads, insecurity because of conflict and access restrictions by parties of the conflict were the main issues in transport and logistics (WFP, 2004). Levels of food aid for 2005 are not yet published but are expected to be very high. At the beginning of 2005, it was estimated that 5.8 million people would be in need of food aid, including both parts of the country (WFP, FAO, NGOs, GOS & SSC, 2005).
II.3 Food consumption
National level surveys Information on food consumption is limited. No national surveys have been carried out. A study conducted by the Ministry of Health and the World Health Organization (1997), based on household food frequency questionnaires, showed that in the six states surveyed (Kassala, South Darfur, North Kordofan, Red Sea, Gezira and Nahr El Neil), 24% of the total population consumed meat daily and 38% consumed it 2 to 3 times a week. This study revealed that 73% consumed milk every day. Only 12% of the households consumed green leafy vegetables daily and the same percentage consumed other vegetables daily. It also showed that only 8% consumed fruit daily. Most of the population (86%) had three meals per day and 13% had only two meals (MOH & WHO, 1997).
II.4 Infant and young child feeding practices
Infant and young child feeding practices are documented through a national survey conducted in 2000. Among infants under four months of age, about a fifth were exclusively breastfed. This proportion decreased to 16% for infants under six months. Between 6 and 9 months, less than half of the infants received complementary food in addition to breastmilk (FMH, CBS & UNICEF, 2001). Typically, infants and young children receive complementary foods only once or twice a day. Basic porridges are often given, based on the local staple food. Such porridges are generally prepared with water of uncertain quality, causing diarrhea (ENN & GIFA Project, 2003). Approximately 84% of children continued to be breastfed at age 12-15 months and 40% at age 20-23 months (FMH, CBS & UNICEF, 2001). Among children under three years, the median duration of breastfeeding was about 19 months in 1990 (ORC Macro, StatCompiler). While breastfeeding is a rather common practice in Sudan, progress must still be done to promote exclusive breastfeeding up to 6 months, and encourage a timely complementation of breastmilk with nutritious foods at 6-9 months.
3 Emergency food aid is destined to victims of natural or man-made disasters; Project food aid aims at supporting specific poverty-alleviation and disaster-prevention activities; Programme food aid is usually supplied as a resource transfer for balance of payments or budgetary support activities. Unlike most of the food aid provided for project or emergency purposes, it is not targeted to specific beneficiary groups. It is sold on the open market, and provided either as a grant, or as a loan.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 22 Table 13: Type of infant and young child feeding Type of feeding in the 24 hours preceding the survey Survey name/date Indicator Percentage Sample size (Reference) by age of children Exclusive breastfeeding rate Multiple Indicator 0-1 month 670 25.6 Cluster Survey, 2-3 months 964 18.5 2000 Sudan Final 4-5 months 983 6.0 Report <4 months 1 634 21.4 (FMH, CBS & <6 months 2 617 15.6 UNICEF, 2001) Timely complementary feeding rate 6-9 months 1 896 46.6 Bottle-feeding rate 0-11 months n.a. n.a. Continued breastfeeding rate 12-15 months (1 year) 1 710 83.5 20-23 months (2 years) 591 40.4 n.a.: not available.
The number of hospitals or maternities officially designated by UNICEF as “Baby Friendly” (i.e. having fulfilled the 10 criteria supportive of breastfeeding) is 25 out of a total of 215 hospitals (UNICEF, 2002b). In 1998, the International Code of Marketing of Breastmilk Substitutes was enforced to end free distributions of infant formula to new mothers.
II.5 Nutritional anthropometry
Low birth weight In 2000, the prevalence of low birth weight (less than 2500g) was high, 31% of neonates in northern Sudan and 17% in the towns of the south. A survey estimated that 87% of births were assisted by skilled health personnel in the year prior to the survey (FMH, CBS & UNICEF, 2001), but this proportion seems improbably high given the limited number of health facilities and personnel, thus the validity of the prevalence of low birth weight is unsure. The Sudan Declaration for Safe Motherhood signed in August 2001 by the Federal Ministry of Health and the States Ministers of Health calls for a reduction of maternal and neonatal morbidity and mortality through increasing percentage of deliveries attended by skilled persons and providing emergency obstetric care (WHO & FMH, 2004).
Anthropometry of preschool children A national survey, conducted in 2000, provides data on prevalence of stunting, underweight and wasting among underfives from 16 regions of northern Sudan (FMH, CBS & UNICEF, 2001). Another earlier survey provided data with less extensive regional coverage (MOH & WHO, 1997). In 2000, the prevalence of malnutrition among children under five years was very high, reflecting the critical nutrition situation inherited from the past decades. Overall, 41% of children were underweight and 15% were severely underweight. There were regional variations in prevalence, with the highest prevalence observed in Northern Kordufan (50%). Children of mothers with no education were more likely to be underweight than those of mothers with higher education (45% and 35% respectively) (FMH, CBS & UNICEF, 2001). Stunting (chronic malnutrition) affected 43% of underfives and 24% were severely stunted. In general, children residing in rural areas and those born to mothers with low education were more likely to be affected by chronic malnutrition. There were significant regional variations in the prevalence of stunting, ranging from 31% in River Nile to 59% in Kassala (FMH, CBS and UNICEF, 2001). Stunting
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 23 prevalence was higher than 40% in the eastern states (Red Sea, Kassala, Al-Gadarif, Sinnar and Blue Nile), and some central and western states (all Darfur states and Northern Kordofan and Western Kordofan). Most of these states are not affected by conflict, but the eastern part of the country receives refugees from bordering countries, which disrupts livelihoods of the resident population. Overall, 16% of the children were wasted (acute malnutrition). Severe acute malnutrition affected 4% of the children. The prevalence of wasting varied by region, and levels were particularly high in Northern Darfur, where 23% of the children were wasted (FMH, CBS & UNICEF, 2001). A comparison between data from 1995 (MOH & WHO, 1997) and 2000 (FMH, CBS & UNICEF, 2001) is only possible for 5 regions. The comparison shows that stunting increased in all regions except Gezira, and the increase was important, up to approximately 20 percentage points in Kassala for example. Such large changes in stunting prevalence occurring over a short period of time are unlikely, therefore they could be due to differences in methodology or in sampling. Thus the trends must be interpreted with caution. Moreover changes in prevalence of wasting are also inconsistent, as wasting increased in 3 regions and decreased in 2, and the 1995 survey report does not specify the season when the survey was conducted (MOH & WHO, 1997; FMH, CBS & UNICEF, 2001). Few data are available after 2001, but significant increases in malnutrition rates were observed in the Darfur region (CDC & WFP, 2004). A survey was carried out in September 2004 in a crisis-affected population residing in an area covering all three states of Darfur, among 842 children 6-59 months. The prevalence of wasting among these children was 22%. The high child malnutrition rates in the Darfur were directly linked to the on-going crisis, loss of livelihoods and internal displacement (CDC & WFP, 2004). Another survey conducted among children 6-59 months in rural Red Sea and Kassala States in 2004, which were not affected by conflict, also showed persisting high rates of stunting (respectively 39 and 44%). The surveys were conducted before the hungry season (February-March), thus the observed rates of wasting (respectively 19 and 18%) could be lower than those following the period of food shortage (WFP, FAO, UNDP & UNICEF, 2005). In conclusion, national data from the year 2000 and some regional data from 2004 show that many states not affected by conflict have a critical nutrition situation with high prevalences of wasting and stunting. Some of the factors contributing to this situation are chronic food insecurity, poor access to water and sanitation, poor dietary and infant feeding practices, and a high incidence of infectious and parasitic diseases such as malaria and diarrhea, among others. Low birth weight is highly prevalent, and both stunting and wasting prevalences are high from birth, indicating that poor nutritional status of mothers is probably a very important determinant of malnutrition in the country.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 24 Table 14: Anthropometry of preschool children Prevalence of malnutrition Name/date Percentage of children with of survey Background Age Sample Sex Stunting Wasting Underweight Overweight (month/year) characteristics (years) size (Reference) Height-for-age Weight-for-height Weight-for-age Weight-for-height < -3 Z-scores < -2 Z-scores* < -3 Z-scores < -2 Z-scores* < -3 Z-scores < -2 Z-scores* > +2 Z-scores Total 0-4.99 M/F 18 043 23.7 43.3 3.8 15.7 14.7 40.7 3.4 Multiple Sex 0-4.99 M 9 018 23.9 43.6 4.4 16.9 14.6 41.6 3.0 Indicator 0-4.99 23.5 43.1 3.2 14.5 14.7 39.7 Cluster Survey, F 9 025 3.9 Sudan Final Age Report 0-0.49 M/F 1 838 5.9 11.7 3.6 11.3 1.7 6.2 11.3 (Jul-Aug. 2000) 0.5-0.99 M/F 2 001 15.0 29.5 4.4 18.3 11.2 32.0 5.3 (FMH, CBS & 1-1.99 M/F 2 898 24.7 46.7 6.6 24.6 19.6 50.5 3.3 UNICEF, 2001) 2-2.99 M/F 3 918 29.3 49.6 4.8 17.3 23.1 51.7 1.6 3-3.99 M/F 3 978 30.1 52.7 2.2 12.2 13.7 43.6 2.4 4-4.99 M/F 3 411 23.5 47.5 2.0 11.2 10.9 39.9 1.6 Residence
urban 0-4.99 M/F 9 098 19.4 38.5 3.7 14.4 11.3 36.0 3.7
rural 0-4.99 M/F 8 945 28.0 48.2 3.9 16.9 18.0 45.4 3.2 Region Northern 0-4.99 M/F 326 17.9 35.8 3.4 17.4 10.8 36.9 3.7 River Nile 0-4.99 M/F 508 13.0 30.5 3.6 20.2 11.3 38.9 0.6
Red Sea 0-4.99 M/F 220 23.2 41.7 3.2 15.6 18.2 42.3 3.6
Kassala 0-4.99 M/F 1 599 36.2 59.4 2.5 8.6 9.6 31.6 6.1 Al-Gadarif 0-4.99 M/F 874 28.5 48.7 4.9 16.1 20.9 48.8 1.8 Al-Gazira 0-4.99 M/F 1 402 19.5 38.4 5.7 20.2 14.8 41.8 2.4 Sinnar 0-4.99 M/F 857 25.2 49.1 4.0 15.0 17.0 44.5 2.5
White Nile 0-4.99 M/F 1 637 18.4 36.0 5.8 21.8 16.7 43.3 1.8 Blue Nile 0-4.99 M/F 593 25.8 47.4 3.1 13.8 16.0 43.9 4.0 Khartoum 0-4.99 M/F 2 596 15.3 32.1 1.9 13.9 10.4 36.3 2.3 Nothern Kordufan 0-4.99 M/F 1 126 24.3 45.5 3.0 19.3 19.1 49.9 0.9 Southern Kordufan 0-4.99 M/F 883 21.0 39.1 2.1 10.7 10.7 32.8 2.6
Western Kordufan 0-4.99 M/F 871 31.0 49.3 5.1 18.2 18.9 43.8 6.5 Nothern Darfur 0-4.99 M/F 1 378 22.4 44.3 5.9 22.5 18.8 47.4 2.2 Southern Darfur 0-4.99 M/F 2 338 26.7 46.7 3.6 12.4 14.3 39.4 4.7 Western Darfur 0-4.99 M/F 835 32.2 51.2 3.8 8.8 14.4 37.4 10.5 Mother's education no education 0-4.99 M/F 10 270 28.5 49.3 4.1 16.6 17.8 45.4 n.a. primary 0-4.99 M/F 327 29.4 53.8 1.6 9.5 12.0 39.9 n.a. secondary or higher 0-4.99 M/F 7 158 17.2 35.4 3.5 14.8 10.8 34.7 n.a. * Category <-2 Z-scores includes <-3 Z-scores / Data on overweight taken from WHO Global Database on Child Growth and Malnutrition / n.a.: not available.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 25 Table 14: Anthropometry of preschool children (cont.) Prevalence of malnutrition Name/date Percentage of children with of survey Background Age Sample Sex Stunting Wasting Underweight Overweight (month/year) characteristics (years) size (Reference) Height-for-age Weight-for-height Weight-for-age Weight-for-height < -3 Z-scores < -2 Z-scores* < -3 Z-scores < -2 Z-scores* < -3 Z-scores < -2 Z-scores* > +2 Z-scores Total 0-4.99 M/F 3 099 16.1 34.8 3.4 17.1 13.1 38.5 1.6 Comprehensive Sex nutrition 0-4.99 16.8 34.6 3.7 18.4 13.2 38.1 survey, M 1 633 1.3 1995 0-4.99 F 1 466 15.3 35.0 3.1 15.6 13.1 38.9 2.0 (MOH & WHO, Age 1997) 0-0.49 M/F 188 0.5 5.9 2.7 6.9 1.6 7.4 9.0 0.5-0.99 M/F 466 9.2 24.7 2.4 13.3 8.6 26.8 3.0
1-1.99 M/F 835 16.4 39.8 6.1 26.5 16.2 45.0 1.3 2-2.99 M/F 726 18.0 36.1 3.0 17.5 16.7 44.8 0.4 3-3.99 M/F 522 22.4 39.3 1.9 13.0 12.5 41.0 1.0 4-4.99 M/F 326 19.6 42.9 1.8 10.1 11.3 37.7 0.3
Residence
urban 0-4.99 M/F n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. rural 0-4.99 M/F n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. Region Gezira 0-4.99 M/F 507 21.9 38.3 2.2 17.6 14.6 39.6 2.6 Kassala 0-4.99 M/F 555 14.4 35.5 2.9 17.3 10.3 38.7 1.1 Nahr El Neil 0-4.99 M/F 413 19.6 40.0 6.8 23.0 17.7 39.7 3.6 North Kordofan 0-4.99 M/F 562 12.3 31.9 1.8 15.1 10.3 39.9 1.4 Red Sea 0-4.99 M/F 520 17.9 36.5 6.5 23.8 19.8 45.8 1.3 South Darfur 0-4.99 M/F 556 12.4 28.8 1.3 7.7 7.9 28.2 0.4 Mother's education no education 0-4.99 M/F n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. primary 0-4.99 M/F n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. secondary or higher 0-4.99 M/F n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. * Category <-2 Z-scores includes <-3 Z-scores. Note: Category "Total" includes 6 states pooled (Kassala, South Darfur, North Kordofan, Red Sea, Gezira and Nahr el Neil). ¹ Data taken from WHO Global Database on Child Growth and Malnutrition. n.a.: not available.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 26
Anthropometry of school-age children and adolescents No data are currently available on anthropometry of school-age children and adolescents.
Anthropometry of adult women Few data are available on anthropometry of adult women. The Comprehensive Nutrition Survey (MOH & WHO, 1997) provides some information on anthropometry of mothers. In 1995, the prevalence of chronic energy deficiency (CED) among 3 586 mothers (age not specified) was 18%. The highest prevalence was among mothers from North Kordofan (32%) and the lowest was in the Gezira State and in South Darfur (5% for both) (MOH & WHO, 1997). According to the SuRF report, the mean BMI of women (≥15 years of age) was 22.5 kg/m² in 2002. The prevalence of overweight among women was 27% and that of obesity was 4% (WHO, 2005). Nevertheless representativeness of the data is not documented.
Anthropometry of adult men According to the SuRF report, in 2002, the mean BMI of men (≥15 years of age) was 21.5 kg/m². The prevalence of overweight was 16% and that of obesity was 1% (WHO, 2005). Representativeness of the data is not documented.
II.6 Micronutrient deficiencies
Iodine deficiency disorders (IDD) Prevalence of goitre and urinary iodine level A survey conducted in 1997 in seven regions of northern Sudan among school-age children revealed that goitre was widespread except in two regions where prevalence was low (Eastern Zone and Khartoum State). Overall, 22% of school-age children were affected by goitre (MOH & WHO, 1999). The median level of urinary iodine was the lowest in the Darfur Zone (median 20µg/L) and the highest in the Eastern Zone (median 98µg/L). Low urinary iodine was extremely common (<100µg/L which defines mild IDD), as at least half of school-age children had low levels, and virtually all the children had low levels in the Upper Nile Zone (98%) (MOH & WHO, 1999). Osman & Fatah (1981) suggested that the presence of goitrigens in the diet could be a cause of IDD, but the main cause remains low iodine intake.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 27
Table 15: Prevalence of goitre and level of urinary iodine in school-age children Prevalence of goitre Level of urinary iodine
Percentage Survey name/date Background Age Percentage Sex Sample Sample Median with urinary (Reference) characteristics (years) with goitre size size (µ g/L) iodine [Total Goitre] <100µg/L
Total SAC M/F 40 922 22.0 n.a. n.a. n.a. IDD Baseline Region Survey Report, Darfur Zone SAC M/F 4 835 27.6 240 19.9 89.2 (1997) (MOH & WHO, Kordofan Zone SAC M/F 4 503 39.1 600 48.2 79.8 1999) Upper Nile Zone SAC M/F 1 874 42.2 311 40.3 97.8 Northen Zone SAC M/F 5 773 38.1 600 90.5 54.9 Eastern Zone SAC M/F 7 937 8.2 594 97.9 52.0 Khartoum State SAC M/F 8 135 5.4 600 92.6 55.0 Central Zone SAC M/F 7 865 22.7 599 70.4 74.5 SAC: School-age children. n.a.: not available.
Iodization of salt at household level A specialized unit for IDD treatment, control and prevention was formed by the Ministry of Health with support of UNICEF in 1989, together with a national programme of endemic goitre control (Elnagar, 1996; Khattab, 1996). The major activities of the IDD unit include prevalence surveys, iodized oil distribution in endemic areas, laboratory monitoring and training. Legislation on salt iodization exists in Sudan since 1994, but large-scale salt iodization only started in 2000. All salt (73 000 tons in 2000) is produced in the private sector, is not refined, and contains impurities. It needs to be washed before iodization to be pure enough to retain the iodine, which is a costly procedure. Salt marketing is said not to be controlled. Very little salt reaches the west of the country. UNICEF recently donated 11 iodizing machines and a semi-manual unit for Darfur state (ICCIDD, 2002). A survey conducted in 2000, showed that consumption of properly iodized salt was very rare, except in the South Darfur region where 3% of households used it (FMH, CBS & UNICEF, 2001).
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Table 16: Iodization of salt at household level Number of Iodine level of household salt Survey name/date Background households where Percentage of (Reference) characteristics salt was available Inadequate Adequate households tested for testing (<15 ppm) ( ≥15 ppm)
Total 24 067 99.5 0.5 97.1 Multiple Indicator Residence Cluster Survey, 2000 Urban 12 072 99.2 0.8 97.4 Sudan Final Rural 12 009 99.8 0.2 96.9 Report Region (FMH, CBS & Northern 680 100.0 0.0 98.8 UNICEF, 2001) River Nile 959 100.0 0.0 99.3
Red Sea 907 99.8 0.2 99.9 Kassala 1 269 99.1 0.9 98.2 Al-Gadarif 1 237 99.8 0.2 93.2 Al-Gazira 3 247 100.0 0.0 98.8 Sinnar 1 183 99.9 0.1 99.1 White Nile 1 463 100.0 0.0 99.0 Blue Nile 488 99.9 0.1 99.1 Khartoum 3 207 100.0 0.0 99.0 North Kordufan 1 717 99.9 0.1 99.3 South Kordufan 833 100.0 0.0 97.9
West Kordufan 846 100.0 0.0 73.6 North Darfur 1 590 99.7 0.3 99.6 South Darfur 2 653 97.1 2.9 97.3 West Darfur 1 798 99.1 0.9 96.4 Note: ppm: parts per million.
Vitamin A deficiency (VAD) Prevalence of sub-clinical and clinical vitamin A deficiency In 1995, a survey conducted in six regions of the country showed a prevalence of 8.5% of night blindness in children under five years. Three percent of the children presented Bitot spots (classification X1B). There were, however, important variations by region, ranging from 7.4% in South Darfur to 0.2% in Kassala. Corneal xerosis (classification X2) occurred among 0.1% of the children. The prevalence of corneal xerosis was higher in South Darfur (0.5%) and in Red Sea (0.2%) (MOH & WHO, 1997). A survey carried out in the Darfur zone in 2004, in the population affected by the crisis (IDP and residents), did not find any Bitot spots in a sample of 844 children 6-59 months, but 16% of their mothers reported having experienced night-blindness during their last pregnancy (CDC & WFP, 2004).
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Table 17: Prevalence of clinical vitamin A deficiency in children under 5 years
Clinical signs of xerophthalmia Survey name/date Background Age Sex (Reference) characteristics (years) Sample size Type of sign Percentage
Total 0.49-4.99 M/F 3 576 Bitot's Spots 3.2 Comprehensive 0.49-4.99 M/F 3 576 Corneal Xerosis 0.1 nutrition survey 1995 Region (MOH & WHO, 1997) South Darfur 0.49-4.99 M/F 596 Bitot's Spots 7.4 Gezira 0.49-4.99 M/F 597 Bitot's Spots 7.0 Kassala 0.49-4.99 M/F 599 Bitot's Spots 0.2 North Kordofan 0.49-4.99 M/F 599 Bitot's Spots 1.8 Nahr El Neil 0.49-4.99 M/F 594 Bitot's Spots 1.7 Red Sea 0.49-4.99 M/F 591 Bitot's Spots 1.4
South Darfur 0.49-4.99 M/F 596 Corneal Xerosis 0.5 Gezira 0.49-4.99 M/F 597 Corneal Xerosis 0.0 Kassala 0.49-4.99 M/F 599 Corneal Xerosis 0.0 North Kordofan 0.49-4.99 M/F 599 Corneal Xerosis 0.0 Nahr El Neil 0.49-4.99 M/F 594 Corneal Xerosis 0.0 Red Sea 0.49-4.99 M/F 591 Corneal Xerosis 0.2
The high occurrence of VAD in the country is related to dietary patterns and lack of access to good food sources of vitamin A, compounded by a high prevalence of malnutrition. Consumption of animal products and fruit and vegetables, especially green leafy varieties, is limited (MAF, 1991). Although the national supply of milk is abundant, not all population groups have access to dairy products.
Vitamin A supplementation The MICS survey of 2000 documents Vitamin A supplementation in the northern part of the country (FMH, CBS & UNICEF, 2001). In the six months before the survey, 44% of children aged 6-59 months had received a high dose supplement. Coverage was slightly higher in urban areas but there were very large regional variations, from 18% in Southern Darfur to 67% in Khartoum. Only 22% of mothers received supplements within 2 months postpartum. In Southern Darfur, only 13% of mothers received supplements, the lowest figure among all regions (FMH, CBS & UNICEF, 2001). A more comprehensive strategy has been developed by the government to control and prevent VAD. It includes prophylactic and treatment doses in Mother and Child Health (MCH) centres. There are plans to integrate the activities of MCH with the extended programme of immunization (EPI) and the acute respiratory infection programme (ARI). The Ministry of Agriculture promotes production and consumption of fruit and vegetables, and nutrition education programmes emphasize the importance of a mixed and varied diet, particularly among mothers (MOH & WHO, 1997).
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Table 18: Vitamin A supplementation of children and mothers Children Mothers Percent Percent of children of mothers who who received Survey name/date Background Number Number received Age vit. A Age (Reference) characteristics Sex of of vit. A (months) supplements (years) children mothers¹ supplements in the 6 within 2 months months preceding the postpartum survey Total 0.49-4.99 M/F 20 639 44.3 n.a. 6 872 21.9 Multiple Indicator Sex Cluster Survey, 0.49-4.99 M 10 359 44.6 2000 Sudan Final 0.49-4.99 F 10 276 43.9 Report Residence (FMH, CBS & Urban 0.49-4.99 M/F 10 162 48.9 n.a. 3 477 26.8 UNICEF, 2001) Rural 0.49-4.99 M/F 10 477 39.8 " 3 395 16.8 Region Northern 0.49-4.99 M/F 408 35.6 " 133 28.5 River Nile 0.49-4.99 M/F 541 61.5 " 192 23.9 Red Sea 0.49-4.99 M/F 402 33.4 " 160 20.9 Kassala 0.49-4.99 M/F 1 607 59.1 " 519 23.4 Al-Gadarif 0.49-4.99 M/F 1 063 31.9 " 247 20.0 Al-Gazira 0.49-4.99 M/F 2 558 43.2 " 667 19.3 Sinnar 0.49-4.99 M/F 889 52.3 " 326 17.6 White Nile 0.49-4.99 M/F 1 713 57.1 " 440 18.3 Blue Nile 0.49-4.99 M/F 574 62.0 " 166 18.7 Khartoum 0.49-4.99 M/F 2 661 67.4 " 849 45.5 Northern Kordufan 0.49-4.99 M/F 1 162 33.3 " 430 18.3 Southern Kordufan 0.49-4.99 M/F 852 41.8 " 367 12.6 Western Kordufan 0.49-4.99 M/F 998 30.2 " 408 16.9 Nothern Darfur 0.49-4.99 M/F 1 446 47.2 " 623 20.2 Southern Darfur 0.49-4.99 M/F 2 466 18.2 " 833 12.7 Western Darfur 0.49-4.99 M/F 1 298 27.8 " 514 20.7 ¹ Women with a birth in the 12 months preceding the survey. For women with two or more births during that period, data refer to the most recent birth. n.a.: not available.
Iron deficiency anemia (IDA) Prevalence of IDA Nutritional anemia is among the ten major causes for hospital admission in Sudan. However, nationally representative data on iron deficiency are limited in the country. In 1995, the prevalence of anemia (defined as hemoglobin<11.0g/dL) in children under five years was very high, and in almost all states surveyed, more than 80% of children were anemic. In Khartoum the prevalence was the lowest but affected almost one third of children (MOH & WHO, 1997). In 2004, in the crisis-affected population of Darfur, the prevalence of anemia was 55%. Severe anemia affected more than 1% of children (CDC & WFP, 2004).
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Table 19: Prevalence of anemia in preschool children Percentage of children with Survey name/date Background Age Sample Sex (Reference) characteristics (years) size Any anaemia (Hb<11.0 g/dL) Region Comprehensive South Darfur 0-4.99 M/F 300 86.4 nutrition survey 1995 Gezira 0-4.99 M/F 300 82.9 (MOH & WHO, 1997) Kassala 0-4.99 M/F 300 81.7 North Kordofan 0-4.99 M/F 300 90.8 Nahr El Neil 0-4.99 M/F 300 92.1 Red Sea 0-4.99 M/F 300 89.1 Khartoum 0-4.99 M/F n.a. 32.0 Hb: Hemoglobin. n.a.: not available.
The 1995 survey also showed that prevalence of anemia was high among women of childbearing age. More than half of the women 15-45 years of age were anemic in the states of the Red Sea and Gezira (56%). Prevalence was much lower in Khartoum compared with all the other regions (21%) (MOH & WHO, 1997). In Darfur in 2004, 28% of non-pregnant mothers were anemic (Hb<12g/dL) and 1% had severe anemia. Nineteen percent of pregnant mothers were classified as anemic (Hb<11g/dL). There was no case of severe anemia identified among pregnant women. The mean hemoglobin concentration was 13g/dL and 12g/dL for non-pregnant and pregnant mothers, respectively (CDC & WFP, 2004). Table 20: Prevalence of anemia in women of childbearing age Percentage of women with Survey name/date Background Age Sample (Reference) characteristics (years) size Any anemia (Hb<12.0 g/dL) Region Comprehensive South Darfur 15-45 150 39.2 nutrition survey 1995 Gezira 15-45 150 55.6 (MOH & WHO, 1997) Kassala 15-45 150 37.4 North Kordofan 15-45 150 44.9 Nahr El Neil 15-45 150 53.1 Red Sea 15-45 150 56.4 Khartoum 15-45 n.a. 20.8 Hb: Hemoglobin. n.a.: not available.
IDA can be caused by diets with low bioavailability of iron. The limited consumption of meat is probably a major cause of anemia. In 1995, 24% of the households surveyed were consuming meat daily, the majority (38%) were consuming meat only 2 or 3 times a week (MOH & WHO, 1997). Moreover, the Sudanese diet is mainly composed of cereals with a high phytate content which limits bioavailability of iron. Parasitic diseases are very common and are also an important cause of IDA. Schistosomiasis is one of the main endemic water-borne diseases in Sudan. It is endemic in all states except Red Sea. Twenty four million people are at risk of contracting the infection. The prevalence ranged between 28 and 80% among school children surveyed in central states in 2001 (FMH, 2003). Moreover, malaria is widespread in the country. In 2000, the malaria-related mortality rate in underfives was 408 per 100 000 deaths (UNSTAT).
Interventions to combat IDA Control measures through the distribution of iron and folic acid tablets to pregnant and lactating mothers is widely practiced at the Ministry of Health centres, coupled with nutrition and health education.
Sudan Nutrition Profile – Food and Nutrition Division, FAO, 2005 32
II.7 Policies and programmes aiming to improve nutrition and food security
Regarding the nutritional situation of the country, especially that concerning children, there is a lack of nutritional policy to set priorities and guide the work (WHO & FMH 2004). The health policy system in Sudan has experienced marked reform, although still not fully shaped, in its strategic direction (WHO & FMH, 2004). The government is developing a strategic plan for health promotion. The Strategic Plan for the Health Sector defines the priorities for the coming 25 years. Health policy priorities are focused on provision of essential health care, achievement of health for all through a broadened primary health care concept, focus on the poor and vulnerable and development of human resources. Health priorities include improving health service coverage and accessibility, eliminating geographic and financial barriers, building capacity and improving management of the health system (FMH, 2003). This strategic plan aims to achieve the Millennium Development Goals. The Ten-Year National Comprehensive Strategy plan for 1992–2001 aimed to ensure food security by increasing livestock production. The key elements of the strategy were increased production and export of livestock, diversification of animal and crop production, encouragement of a gradual shift towards permanent settlement of migrant pastoralists, development of extension, training and information services, privatisation of public enterprises, improvement and expansion of fisheries and aquaculture industries and improvement in marketing (Fadlalla & Ahmed, 2003).
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